As medical technology advances, surgical procedures are increasingly being achieved through endoscopy. The main advantages of using endoscopy for various types of surgery is that the minimally invasive endoscope decreases surgical operating time and reduces post-operative complications, such as bacterial infection. This, in turn, reduces the patient's discomfort, recovery time and hospital stay. In particular, elderly patients who are vulnerable to the risks associated with prolonged general anesthesia and healing from major surgery benefit from endoscopic modifications of traditional surgical procedures.
An example of a surgical procedure which has been improved by endoscopy is the procedure to correct stress urinary incontinence in females. In stress urinary incontinence, the patient leaks urine in response to a sudden increase in the intra-abdominal pressure secondary to such acts as coughing, sneezing, laughing, and lifting. Problems with connective tissue support of the proximal urethra and vesical neck are by far the most common causes of stress incontinence. See, DeLancey, "Anatomy and Physiology of Urinary Continence," Clin. Ob. & Gyn., 33(2): 298-307 (1990). In the average woman in the supine position, the urethral pressure ranges from 40 to 80 cm H.sub.2 O and the intra-abdominal pressure from 5 to 10 cm H.sub.2 O. During coughing or stress maneuvers, there is an increase of 20 to 100 cm H.sub.2 O in abdominal and bladder pressures. However, urinary incontinence does not occur in normal women for three reasons. First, a reflex contraction of the pelvic floor muscles increases urethral pressure. Second, the normal female urethra is in a well-supported retropubic position; therefore, any increase in pressure is transmitted to the bladder, urethra, and bladder neck, thus maintaining the pressure gradient. Third, the locus of force generated is experienced, not at the bladder neck (located in a non-dependent position), but at the bladder base, which is the most dependent structure. See, Snyder and Lipsitz, "Evaluation of Female Urinary Incontinence," Urological Clinics of N. Amer., 18(2): 197-209 (1991).
A modified Burch's procedure, or Marshall-Marchetti-Krantz operation, attempts to alleviate stress urinary incontinence in females by resecuring the urethra in its normal retropubic position. This procedure generally requires placement of sutures between the paraurethral tissues of the anterior vaginal mucosa and the periosteum of the pubic bone. Either one or two (but sometimes three or more) pairs of sutures are placed, depending upon the particular case and the preference of the surgeon. A final one or two sutures are taken to fix the anterior aspect of the bladder to the superior aspect of the symphysis. This suture is passed from Cooper's ligament on the one side, into the bladder wall at the midline, and to the Cooper's ligament on the other side. This successfully suspends the bladder neck to relieve gravitational tension thereon. See, Ridley, "Technique of the Marshall-Marchetti-Krantz Operation," in Gynecological Surgery: Errors, Safeguards, Salvage, 2nd Ed., pp. 194-197 (1981).
The fact that different variations of these surgical procedures have been developed for the treatment of stress incontinence reflects the current lack of complete success in the field. See, Fischer-Rasmussen, "Treatment of Stress Urinary Incontinence," Ann. Med., 22:455-465 (1990). Due to the apparent advantages of endoscopy, the modified Burch's procedure for the correction of stress urinary incontinence has been adapted for the endoscopic delivery of the necessary sutures. See, Stanton, "Surgical Management of Urethral Sphincter Incompetence," Clin. Ob & Gyn., 33(2): 346-357 (1990).
Presacral corpopexy for the correction of vaginal prolapse similarly requires the placement of sutures in the apex of the vaginal cavity to approximate pre-sacral ligaments. When presacral corpopexy is performed via conventional surgical techniques, a very large abdominal incision is required to reach the presacral ligament. See, Romney et at., "Disorders of Pelvic Support" in Gynecology and Obstetrics, The Health Care of Women, pp.974-977 (1981). Therefore, this procedure has also been adapted for endoscopic surgery with some success.
The risks of traditional surgery have been partially reduced through the adaptation of endoscopy to these and other procedures, however, the currently employed practices require the insertion of two separate surgical tools in addition to the endoscope for conventional needle placement and securing of sutures in the appropriate tissue. Thus, the current endoscopic tools and procedures require making an unnecessary additional incision in the patient, and require the assistance of a second surgeon or surgical assistant during the procedure to aid in suture placement.
Furthermore, current endoscopes and procedures require a series of unnecessary movements within the surgical site to secure and manipulate sutures during placement, which increases tissue trauma and the chances of surgical errors occurring. This is especially true when the procedure is performed on very delicate tissues and in a confined space, such as in a modified Burch's procedure for stress urinary incontinence or a presacral corpopexy procedure for vaginal prolapse, as described above.
Advances toward reducing the surgical risk associated with endoscopic repair of stress urinary incontinence have focused on improved needle design for use with endoscopic needle drivers. The Stamey-type needle is a preferred needle for use in endoscopic repair of stress urinary incontinence. See, Davis and Lobel, "Laparoscopic Urothropexy For The Correction Of Stress Urinary Incontinence And Cystocele: Evolution Of Technique And Results Of A Pilot Study" (1993). Endoscopic suture placement with a needle, however, still requires additional time, manpower and trauma. Thus, there is a need in the an to provide a single endoscopic surgical device which provides rapid effective securing of sutures at a desired location.